Leadership Macomb, Inc. · JLM Application Class XI

Contact Information

Name

First Name

Last Name

Preferred Name

*

Student Email

*

Verify Email

*

Student Cell

*

Home Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Date of Birth

*

(mm/dd/yyyy)

High School

*

School District

*

Special Accommodations

*

Do you have any special dietary restrictions, preferences or do you require special accommodations?

Yes

No

If yes, please explain

Ethnicity

*

Please indicate your ethnicity (ethnicities)

Asian or Pacific Islander

African American

Caucasian

Hispanic

Native American

Middle Eastern

Wish not to disclose

Other (please explain)

Other ethnicity

Non Discrimination Policy

Leadership Macomb does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations. The information collected in this application are for reporting and data collection purposes only.

Do you qualify for free or reduced lunch?

*

Yes

No

T-shirt Size

*

Grade level as of September

*

High School GPA

*

What specific skills or knowledge do you hope to gain from your experience with Junior Leadership Macomb?

*

Please list what you believe are the three most important issues confronting young adults today (no wrong answers).

*

Personal Goals

*

Please describe in 500 words or less your personal goals for the future and how you believe your leadership qualities will help you realize these goals.

Personal Achievements

*

Please list internships, work experience, community service, student organizations or any other personal victories or accomplishments that you believe demonstrates your leadership abilities.

Self-Assesssment

Based on your past experiences and your own self-assessment of your abilities and potential, rate yourself in the following areas (1 is low, 4 is high)

Ability to understand and meet expectations

*

1

2

3

4

Ability to communicate orally

*

1

2

3

4

Ability to get along with others

*

1

2

3

4

Ability to think creatively

*

1

2

3

4

Ability to set and accomplish goals

*

1

2

3

4

Ability to adapt to change

*

1

2

3

4

Attendance/punctuality

*

1

2

3

4

Eagerness to serve my community

*

1

2

3

4

Tuition Agreement

Upon a student’s acceptance into the program, parents/guardians will be billed a non-refundable program fee of $200 which is payable in full by July 1, 2024. Scholarships that cover the entire fee amount are available for individuals who demonstrate a financial need. Financial status will not be a factor in determining eligibility. Any student that would like to be considered for a scholarship must complete the corresponding Scholarship Application section of this application. For additional information regarding scholarships, please contact Julie Petkoff at 586-954-2788.

Scholarship Application

Scholarship awards are based solely on financial need. If you have financial need and would like to apply for a scholarship for this program, please write a short statement demonstrating your need for financial assistance. If this section is not included with your application, you will not be considered for a scholarship.

Parent/Guardian Name

*

First Name

Last Name

Parent/Guardian Phone

*

Parent/Guardian Email

*

Verify Email

*

Upload Parent/Guardian & Student Agreements

Please upload the completed Parent/Guardian & Student Agreements which can be found at the top of this page. You can also send the completed form to Julie Petkoff at jpetkoff@leadershipmacomb.org.

Upload Reference Form

Please upload the completed Reference Form which can be found at the top of this page. You can also send the completed form to Julie Petkoff at jpetkoff@leadershipmacomb.org.

Thank you for applying for Junior Leadership Macomb!

If you do not receive an email from info@leadershipmacomb.org confirming that your application was delivered, please notify us immediately, as your application may not have been successfully submitted.